Health Care Matters | August 30, 2024
Prior Authorization Targeted by More and More States
In recent years, 23 states have enacted over 43 bills related to reigning in the use of prior authorization—with 18 in 2024 alone—according to a National Conference of State Legislatures database. This rise in regulatory oversight is driven by the growth of prior authorization requests, jumping from 37.1 million in 2019 to 46.2 million in 2022 across Medicare Advantage plans. States are continuing to pass bills focused on parts of the market they can regulate, including small-group plans, Medicaid, and the individual market.
Why It Matters
Right care, right place, right time may have sounded nice as a talking point but in practice, limiting access to care through bureaucratic processes like prior authorization can create burdensome administrative work for providers, frustration for patients. We expect continued action from states while Congress is stalled on a federal solution as it relates to Medicare.
Feds Killed Plan To Curb Medicare Advantage Overcharging After Industry Opposition
Kaiser Health News reports this week on documents and depositions released as part of a multi-billion-dollar civil fraud case being brought against UnitedHealth Group by the Department of Justice. Documents reveal glimpses into the actions and conversations between industry lobbyists and advocates and the Centers for Medicare & Medicaid Services after proposed rules were published in January 2014 and then promptly dismissed. The draft regulation which would have required health plans to identify overpayments by CMS and refund them to the government was an attempt by the agency at that time to curb excessive coding with the potential to inflate risk scores and thus the reimbursement.
Why It Matters
While the documents that have come to light in the case relate to actions and conversations that occurred a decade ago, they make transparent the sometimes significant and uncomfortable influence industry advocates may have on public policy for regulators. In light of ongoing challenges to reign in excessive coding and the desire to balance the twin goals of ensuring adequate reimbursement to meet complex health needs with the goal of avoiding overpayment due to egregious coding practices this window into the relationship between policy makers and industry is timely.
What We Are Listening to
Let the General Election Commence
Hear Julie Rovner of KFF Health News, Joanne Kenen of Politico and Johns Hopkins University’s schools of nursing and public health, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico discuss various health issues at play during this years election.
See the Coral Team in Action
Path to VBC Success: Design & Align Incentive Structures
Coral’s own, Maria Alexander, joined Syntax Health co-founders Rachael Jones, MPA and Emily Walker to discuss challenges and lessons learned in designing incentive structures.
